RESUMO
PURPOSE: Using a mixed-methods formative evaluation, the purpose of this study was to provide a broad overview of the Alabama eHealth programme set-up and initial patient outcomes. The Alabama eHealth programme uses telemedicine to provide medical care to people living with HIV in rural Alabama. It was led by a community-based organisation, Medical Advocacy and Outreach (MAO), and supported by AIDS United and the Corporation for National Community Service's Social Innovation Fund with matching support from non-federal donors. METHODS: We conducted and transcribed in-depth interviews with Alabama eHealth staff and then performed directed content analysis. We also tracked patients' ( n = 240) appointment attendance, CD4 counts, and viral loads. FINDINGS: Staff described the steps taken to establish the programme, associated challenges (e.g., costly, inadequate broadband in rural areas), and technology enabling this programme (electronic medical records, telemedicine equipment). Of all enrolled patients, 76% were retained in care, 88% had antiretroviral therapy and 75% had a suppressed viral load. Among patients without missing data, 96% were retained in care, 97% used antiretroviral therapy and 93% had suppressed viral loads. There were no statistically significant demographic differences between those with and without missing data. CONCLUSIONS: Patients enrolled in a telemedicine programme evaluation successfully moved through the HIV continuum of care.
Assuntos
Infecções por HIV/terapia , Acessibilidade aos Serviços de Saúde/organização & administração , Serviços de Saúde Rural/organização & administração , Telemedicina/organização & administração , Adolescente , Adulto , Alabama , Antirretrovirais/uso terapêutico , Registros Eletrônicos de Saúde , Feminino , Infecções por HIV/tratamento farmacológico , Acessibilidade aos Serviços de Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Serviços de Saúde Rural/economia , Fatores Socioeconômicos , Carga Viral , Adulto JovemRESUMO
Few groups in the United States (US) are as heavily affected by HIV as men who have sex with men (MSM), yet many MSM remain unaware of their infection. HIV diagnosis is important for decreasing onward transmission and promoting effective treatment for HIV, but the cost-effectiveness of testing programs is not well-established. This study reports on the costs and cost-utility of the MSM Testing Initiative (MTI) to newly diagnose HIV among MSM and link them to medical care. Cost and testing data in 15 US cities from January 2013 to March 2014 were prospectively collected and combined to determine the cost-utility of MTI in each city in terms of the cost per Quality Adjusted Life Years (QALY) saved from payer and societal perspectives. The total venue-based HIV testing costs ranged from $18,759 to $564,284 for nine to fifteen months of MTI implementation. The cost-saving threshold for HIV testing of MSM was $20,645 per new HIV diagnosis. Overall, 27,475 men were tested through venue-based MTI, of whom 807 (3 %) were newly diagnosed with HIV. These new diagnoses were associated with approximately 47 averted HIV infections. The cost per QALY saved by implementation of MTI in each city was negative, indicating that MTI venue-based testing was cost-saving in all cities. The cost-utility of social network and couples testing strategies was, however, dependent on whether the programs newly diagnosed MSM. The cost per new HIV diagnosis varied considerably across cities and was influenced by both the local cost of MSM testing implementation and by the seropositivity rate of those reached by the HIV testing program. While the cost-saving threshold for HIV testing is highly achievable, testing programs must successfully reach undiagnosed HIV-positive individuals in order to be cost-effective. This underscores the need for HIV testing programs which target and engage populations such as MSM who are most likely to have undiagnosed HIV to maximize programmatic benefit and cost-utility.
Assuntos
Sorodiagnóstico da AIDS/economia , Infecções por HIV/diagnóstico , Infecções por HIV/economia , Homossexualidade Masculina , Programas de Rastreamento/economia , Sorodiagnóstico da AIDS/estatística & dados numéricos , Adulto , Análise Custo-Benefício , Infecções por HIV/epidemiologia , Homossexualidade Masculina/estatística & dados numéricos , Humanos , Masculino , Programas de Rastreamento/métodos , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Minorias Sexuais e de Gênero , Estados Unidos/epidemiologiaRESUMO
PROBLEM: In 2010, the Centers for Disease Control and Prevention (CDC) launched the "Enhanced Comprehensive HIV Prevention Planning" initiative, which targeted funding to the 12 U.S. metropolitan statistical areas (MSAs) with the most severe epidemics of human immunodeficiency virus infection to a) develop a plan to align each MSA's HIV prevention plan with the National HIV/AIDS Strategy (NHAS) and b) identify and implement the optimal combination of prevention services to reduce new infections. PURPOSE: This paper describes how the Maryland Department of Health and Mental Hygiene (DHMH) partnered with the Johns Hopkins Bloomberg School of Public Health (JHSPH) to conduct mathematical modeling and economic analyses to inform local planning for resource allocation and intervention design for the Baltimore-Towson MSA. KEY POINTS: The paper outlines the steps of building and implementing that analytic partnership, illustrates how results were discussed with other key stakeholders, and shows how the findings informed local priority setting. CONCLUSION: The paper demonstrates how health departments, academia, and community partners can jointly use policy modeling to improve resource allocation and address urgent public health challenges.
Assuntos
Pesquisa Participativa Baseada na Comunidade/métodos , Infecções por HIV/prevenção & controle , Promoção da Saúde/métodos , Avaliação de Programas e Projetos de Saúde , Alocação de Recursos/métodos , Serviços Urbanos de Saúde , Baltimore , Centers for Disease Control and Prevention, U.S. , Comportamento Cooperativo , Humanos , Maryland , Saúde Pública , Estados Unidos , População UrbanaAssuntos
Gerenciamento Clínico , Infecções por HIV/prevenção & controle , Infecções por HIV/terapia , Acessibilidade aos Serviços de Saúde/organização & administração , Síndrome da Imunodeficiência Adquirida/prevenção & controle , Síndrome da Imunodeficiência Adquirida/terapia , Fortalecimento Institucional , Comportamento Cooperativo , Troca de Informação em Saúde , Disparidades em Assistência à Saúde/organização & administração , Humanos , Relações Interinstitucionais , Relações Interprofissionais , Estados UnidosRESUMO
Linking and retaining people living with HIV in ongoing, HIV medical care is vital for ending the U.S. HIV epidemic. Yet, 41-44 % of HIV+ individuals are out of care. In response, AIDS United initiated Positive Charge, a series of five HIV linkage and re-engagement projects around the U.S. This paper investigates whether three Positive Charge programs were cost effective and calculates a return on investment for each program. It uses standard methods of cost utility analysis and WHO-CHOICE thresholds. All three projects were found to be cost effective, and two were highly cost effective. Cost utility ratios ranged from $4439 to $137,271. These results suggest that HIV linkage to care programs are a productive and efficient use of public health funds.
Assuntos
Fármacos Anti-HIV/economia , Serviços de Saúde Comunitária/economia , Continuidade da Assistência ao Paciente/economia , Análise Custo-Benefício , Infecções por HIV/terapia , Custos de Cuidados de Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/economia , Fármacos Anti-HIV/uso terapêutico , Chicago , Infecções por HIV/economia , Humanos , Louisiana , Programas Nacionais de Saúde , Cidade de Nova Iorque , Aceitação pelo Paciente de Cuidados de Saúde , Anos de Vida Ajustados por Qualidade de Vida , Estados UnidosRESUMO
UNLABELLED: AIDS United's Positive Charge (PC) was a multiorganizational HIV linkage to care program implemented in five U.S. LOCATIONS: To better understand the process of linkage and reengagement in care, we conducted interviews with care coordinators and program supervisors at 20 PC implementing agencies. Though linkage to care is often considered a single column in the HIV continuum of care, we found that it contains several underlying and often complex steps. The steps described are: identifying individuals in need of services; contacting those individuals through a variety of means; assessing and addressing needs and barriers to care; initial engagement (or reengagement) in HIV primary care; and provision of ongoing support to promote retention. We highlight strategies used to complete these steps. These findings will be of utility to other HIV interventions that aim to improve linkage and engagement in HIV care.
Assuntos
Continuidade da Assistência ao Paciente , Infecções por HIV/diagnóstico , Infecções por HIV/terapia , Acessibilidade aos Serviços de Saúde/organização & administração , Aceitação pelo Paciente de Cuidados de Saúde , Atenção Primária à Saúde/organização & administração , Adulto , Feminino , Infecções por HIV/prevenção & controle , Necessidades e Demandas de Serviços de Saúde , Humanos , Entrevistas como Assunto , Masculino , Pesquisa Qualitativa , Estados UnidosRESUMO
Positive Charge (PC) is a linkage to HIV care initiative implemented by AIDS United with sites in New York, Chicago, Louisiana, North Carolina, and the San Francisco/Bay Area. This study employed standard methods of cost and threshold analyses, as recommended by the US Panel on Cost-effectiveness in Health and Medicine, to calculate cost-saving and cost effective thresholds of the initiative. The overall societal cost of the linkage to care programs ranged from $48,490 to $370,525. The study found that PC's five unique evidence-based linkage to care programs have relatively low costs per client served and highly achievable cost-saving and cost-effectiveness thresholds. The findings from this study suggest that HIV linkage to care programs have the potential to be a highly productive use of public health resources.
Assuntos
Fármacos Anti-HIV/economia , Serviços de Saúde Comunitária/economia , Continuidade da Assistência ao Paciente/economia , Infecções por HIV/economia , Infecções por HIV/terapia , Custos de Cuidados de Saúde/estatística & dados numéricos , Fármacos Anti-HIV/uso terapêutico , Análise Custo-Benefício/métodos , Medicina Baseada em Evidências , Infecções por HIV/transmissão , Acessibilidade aos Serviços de Saúde , Humanos , Masculino , Modelos Econômicos , Programas Nacionais de Saúde , Avaliação de Processos e Resultados em Cuidados de Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Estados UnidosRESUMO
Adequate engagement in HIV care is necessary for the achievement of optimal health outcomes and for the reduction of HIV transmission. Positive Charge (PC) was a national HIV linkage and re-engagement in care program implemented by AIDS United. This study describes three PC programs, the characteristics of their participants, and the continuum of engagement in care for their participants. Eighty-eight percent of participants were engaged in care post PC enrollment. Sixty-nine percent were retained in care, and 46 % were virally suppressed at follow-up. Older participants were more likely to be engaged, retained, and virally suppressed. Differences by race and gender in HIV care and treatment varied across PC programs, reflecting the diverse target populations, locations, and strategies employed by the PC grantees. There is an urgent need for programs that promote HIV care and treatment among vulnerable populations, including young people living with HIV. There is also an urgent need for additional research to test the effectiveness of promising linkage and retention in care strategies, such as peer navigation.
Assuntos
Continuidade da Assistência ao Paciente/estatística & dados numéricos , Infecções por HIV/tratamento farmacológico , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Adolescente , Adulto , Distribuição por Idade , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Acessibilidade aos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Avaliação de Programas e Projetos de Saúde , Carga Viral , Populações Vulneráveis , Adulto JovemRESUMO
There are clear benefits of retention in HIV care, yet millions of people living with HIV are sub-optimally retained. This study described factors from Andersen's behavioral model that were associated with retention in HIV care among 268 female sex workers (FSWs) living with HIV in the Dominican Republic using two measures of retention: a 6-month measure of HIV clinic attendance and a measure that combined clinic attendance and missed visits. FSWs who ever attended HIV care reported high rates (92 %) of 6-month attendance, but 37 % reported missed visits. Using the combined retention measure, the odds of being retained in HIV care were higher among FSWs with more positive perceptions of HIV service providers [adjusted odds ratio (AOR) 1.17; 95 % confidence interval (CI) 01.09, 1.25] and lower among women who reported recent alcohol consumption (AOR 0.50; 95 % CI 0.28, 0.92) and self-stigmatizing beliefs related to sex work (AOR 0.93; 95 % CI 0.88, 0.98). These findings support the hypothesis that retention in HIV care may be best determined through a combined measure as missed visits are an important mechanism to identify in-care patients who require additional support.
Assuntos
Terapia Antirretroviral de Alta Atividade , Atitude Frente a Saúde , Infecções por HIV/tratamento farmacológico , Serviços de Saúde/estatística & dados numéricos , Cooperação do Paciente/estatística & dados numéricos , Participação do Paciente/estatística & dados numéricos , Profissionais do Sexo , Adulto , Consumo de Bebidas Alcoólicas , Instituições de Assistência Ambulatorial , Agendamento de Consultas , Pesquisa Biomédica , República Dominicana , Feminino , Pessoal de Saúde , Política de Saúde , Humanos , Modelos Logísticos , Razão de ChancesRESUMO
The Access to Care (A2C) is a multi-site initiative that seeks to increase the access to and retention in effective HIV healthcare and support services by people living with HIV across the United States. As the initiative implemented evidence-based programs in new settings with diverse populations, it was important to document these innovative efforts to contribute to the evidence base for best practices. In a partnership between Johns Hopkins University, AIDS United, and the A2C sites, a national evaluation strategy was developed and implemented to build knowledge about how linkage to care interventions could be most effectively implemented within the context of local, real-world settings. This article provides an overview of the efforts to develop and implement a national monitoring and evaluation strategy for a multi-site initiative. The findings may be of utility for other HIV interventions that are seeking to incorporate a monitoring and evaluation component into their efforts.
Assuntos
Continuidade da Assistência ao Paciente/organização & administração , Infecções por HIV/terapia , Acessibilidade aos Serviços de Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Avaliação de Programas e Projetos de Saúde/métodos , Comportamento Cooperativo , Medicina Baseada em Evidências , Humanos , Programas Nacionais de Saúde , Formulação de Políticas , Estados UnidosRESUMO
In 2006, Millett published a seminal literature review that examined 12 hypotheses to explain the high rates of HIV among black MSM. This paper augments Millett's article by reviewing the recent literature on behavioral, biomedical, structural, social contextual, psychosocial, and social network factors that affect HIV rates among black MSM. We searched three databases: PubMed, Scopus, and Google Scholar. First we searched all articles that included black or African American and MSM and HIV. We then searched the following terms for each area: behavioral (drug use during sex, crack cocaine use, and serosorting); biomedical (circumcision, STDs, and STIs); structural (access to care, HIV care, ART, HAART, patient-provider communication, HIV quality of care); social contextual (stigma, discrimination, internalized homophobia, internalized heterosexism, medical mistrust, social isolation, and incarceration); psychosocial (peer support and mental health); and social network (sexual mixing, partner characteristics, and social networks) factors. We identified 39 articles to include in this review. We found inconclusive evidence that incarceration, stigma, discrimination, social isolation, mental health disparities, or social networks explain the elevated rates of HIV among black MSM. We found evidence that the differences in rates of HIV between black and white MSM may be explained by differences in STIs, undiagnosed seropositivity, access to care and treatment services, and use of HAART. There is an overwhelming need for HIV testing, linkage to care, retention in care, and adherence programs for black MSM.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Infecções por HIV/epidemiologia , Comportamentos Relacionados com a Saúde , Homossexualidade Masculina , Apoio Social , Negro ou Afro-Americano/psicologia , Infecções por HIV/diagnóstico , Infecções por HIV/psicologia , Necessidades e Demandas de Serviços de Saúde , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Humanos , Masculino , Serviços de Saúde Mental , Fatores de Risco , Parceiros Sexuais , Discriminação Social , Isolamento Social , Estigma Social , Estados Unidos/epidemiologiaRESUMO
The National HIV/AIDS Strategy (NHAS) clearly emphasized the need to provide services to black men who have sex with men (MSM). However, there are no estimates of the unmet HIV-related service delivery needs among black MSM. We estimate that of 195,313 black MSM living with HIV in the US, 50,196 were not yet diagnosed, and 145,118 were aware of their seropositivity (of whom 67,625 were not linked to care and 77,493 were linked to care). Also, of those already diagnosed, ~43,390 had undetectable viral load and 101,728 had detectable viral load. Approximately 19,545 of diagnosed black MSM engage in unprotected risk behavior in serostatus-discordant partnerships. The cost of delivering services needed to meet the NHAS goals is ~$2.475 billion in 2011 U.S. dollars. Mathematical modeling suggests that provisions of these services would avert 6213 HIV infections at an economically favorable cost of $20,032 per quality-adjusted life year saved.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Infecções por HIV/economia , Necessidades e Demandas de Serviços de Saúde/economia , Homossexualidade Masculina , Habitação/estatística & dados numéricos , Adolescente , Adulto , Infecções por HIV/diagnóstico , Infecções por HIV/prevenção & controle , Infecções por HIV/terapia , Soropositividade para HIV , Disparidades em Assistência à Saúde , Humanos , Masculino , Assunção de Riscos , Parceiros Sexuais , Estados Unidos/epidemiologia , Sexo sem Proteção , Carga Viral , Adulto JovemRESUMO
In fiscal year (FY) 2012, the Centers for Disease Control and Prevention (CDC) reallocated their HIV prevention funding to U.S. states, territories, and some cities so as to be more highly correlated with 2008 HIV prevalence. A jurisdiction's HIV prevention funding could drop as low as $750,000 for FY 2016. Iowa was one state that experienced a substantial funding drop, and it chose to undertake a mathematical modeling exercise to inform the following questions: (a) Given current HIV prevention funding for the state, what is the optimal allocation of resources to maximize infections averted? (b) With this "optimal" resource allocation, how many (and what percentage of) HIV infections in the state can be averted? (c) Is the optimal resource allocation sufficient to achieve the National HIV/AIDS Strategy goal of 25% reduction in HIV incidence? and (d) With the "optimal" resource allocation, is the return on the investment such that it might be considered cost-effective? Here, we describe the results of the policy analysis, and the uses of the results.
Assuntos
Análise Custo-Benefício , Infecções por HIV/economia , Infecções por HIV/prevenção & controle , Alocação de Recursos para a Atenção à Saúde/economia , Serviços Preventivos de Saúde/economia , Centers for Disease Control and Prevention, U.S. , Infecções por HIV/epidemiologia , Infecções por HIV/transmissão , Alocação de Recursos para a Atenção à Saúde/métodos , Política de Saúde/economia , Humanos , Incidência , Iowa/epidemiologia , Modelos Econômicos , Modelos Teóricos , Programas Nacionais de Saúde/organização & administração , Prevalência , Estados UnidosRESUMO
Three key policy questions are explored here: Is it still epidemiologically feasible to attain the incidence and transmission rate reduction goals of the U.S. National HIV/AIDS Strategy (NHAS) by 2015? If so, what costs will be incurred in necessary program expansion, and will the investment be cost-effective? Would substantial expansion of prevention services for persons living with HIV (PLWH) augment the other strategies outlined in the NHAS in terms of effectiveness and cost-effectiveness? Eight policy scenarios were constructed based on three factors (two levels each): expansion (or not) of HIV diagnostic services; assumptions regarding levels of effectiveness of HIV treatment in achieving suppressed viral load; and possible levels of expansion of prevention services for PLWH. All scenarios assumed that the NHAS goal of 85 % linkage to HIV care would be fully achieved by 2015. Standard methods of economic evaluation and epidemiologic modeling were employed. Each of the eight policy scenarios was compared to a flat transmission rate comparison condition; then, key policy dyads were compared pairwise. Without expansion of diagnostic services and of prevention services for PLWH, scaling up coverage of HIV care and treatment alone in the U.S. will not achieve the incidence and transmission rate reduction goals of the NHAS. However, timely expansion of testing and prevention services for PLWH does allow for the goals to still be achieved by 2015, and does so in a highly cost-effective manner.